1-MINUTE CONSULT
AIBEK E. MIRRAKHIMOV, MD
Division of Pulmonary, Critical Care, and Sleep Medicine,
University of New Mexico, Albuquerque, NM
FABRIZIO CANEPA ESCARO, MD
Department of Medicine, University of Kentucky
College of Medicine, Lexington, KY
Q: Is chest radiography routinely needed
after thoracentesis?
A: No. After thoracentesis, chest ra-
diography or another lung imaging
study should be done only if pneumothorax is
suspected, if thoracentesis requires more than
1 attempt, if the patient is on mechanical ven-
tilation or has pre-existing lung disease, or if a
large volume (> 1,500 mL) of fluid is removed.
Radiography is also usually not necessary after
diagnostic thoracentesis in a patient breathing
spontaneously. In most cases, pneumothorax
found incidentally after thoracentesis does not
require decompression and can be managed
supportively.
■■ WHAT ARE THE RISKS OF THORACENTESIS?
Thoracentesis is a minimally invasive proce-
dure usually performed at the bedside that in-
volves insertion of a needle into the pleural
cavity for drainage of fluid.1 Diagnostic thora-
centesis should be done in most cases of a new
pleural effusion unless the effusion is small
and with a clear diagnosis, or in cases of typi-
cal heart failure.
Therapeutic thoracentesis, often called
large-volume thoracentesis, aims to improve
symptoms such as dyspnea attributed to the
pleural effusion by removing at least 1 L of
pleural fluid. The presence of active respirato-
ry symptoms and suspicion of infected pleural
effusion should lead to thoracentesis as soon
as possible.
Complications of thoracentesis may be be-
nign, such as pain and anxiety associated with
the procedure and external bleeding at the site
of needle insertion. Pneumothorax is the most
common serious procedural complication and
the principal reason to order postprocedural
chest radiography.1 Less common complications
doi:10.3949/ccjm.86a.17058
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ARAM BARBARYAN, MD TAHA AYACH, MD
Department of Internal Medicine, Department of Medicine, University of Kentucky
University of Kansas Health System, Kansas City, KS College of Medicine, Lexington, KY
GOUTHAM TALARI, MD ADAM GRAY, MD
Department of Internal Medicine, Division of Hospital Department of Medicine, University
Medicine, Henry Ford Health System, Detroit, MI of Kentucky College of Medicine;
Department of Medicine, Lexington Veterans
Affairs Medical Center, Lexington, KY BRIEF ANSWERS
TO SPECIFIC
CLINICAL
QUESTIONS
include hemothorax, re-expansion pulmonary
edema, infection, subdiaphragmatic organ punc-
ture, and procedure-related death. Bleeding
complications and hemothorax are rare even in
patients with underlying coagulopathy.2
Point-of-care pleural ultrasonography is
now considered the standard of care to guide
optimal needle location for the procedure and
to exclude other conditions that can mimic
pleural effusion on chest radiography, such
as lung consolidation and atelectasis.3 High
proficiency in the use of preprocedural point-
of-care ultrasonography reduces the rate of
procedural complications, though it does not
eliminate the risk entirely.3,4
Factors associated with higher rates of Chest
complications include lack of operator pro-
ficiency, poor understanding of the anatomy, radiography
poor patient positioning, poor patient coop- is usually not
eration with the procedure, lack of availabil-
ity of bedside ultrasonography, and drainage of
needed after
more than 1,500 mL of fluid. Addressing these thoracentesis
factors has been shown to decrease the risk of in asymptom-
pneumothorax and infection.1–5
atic patients
■■ HOW OFTEN DOES PNEUMOTHORAX
OCCUR AFTER THORACENTESIS?
Several early studies have examined the in-
cidence of pneumothorax after thoracentesis.
Lack of ultrasonography use likely explains
a higher incidence of complications in early
studies: rates of pneumothorax after thora-
centesis without ultrasonographic guidance
ranged from 5.2% to 26%.6,7
Gervais et al8 analyzed thoracentesis with
ultrasonographic guidance in 434 patients, 92
of whom were intubated, and reported that
pneumothorax occurred in 10 patients, of
whom 6 were intubated. Two of the intubated
patients required chest tubes. Other studies
C L E V E L A N D C L I N I C J O U R N A L O F M E D I C I N E   V O L U M E 8 6 • N U M B E R 6   J U N E 2 0 1 9 371
 RADIOGRAPHY AFTER THORACENTESIS

have confirmed the low incidence of pneumo- of a complication, if thoracentesis required

thorax in patients undergoing thoracentesis, multiple attempts, if the procedure caused
with rates such as 0.61%,1 5%,9 and 4%.10 aspiration of air, if the patient has advanced
The major predictor of postprocedural lung disease, if the patient is scheduled to
pneumothorax was the presence of symptoms undergo thoracic radiation, if the patient is
such as chest pain and dyspnea. No interven- on mechanical ventilation, and after thera-
tion was necessary for most cases of pneumo- peutic thoracentesis if a large volume of flu-
thorax in asymptomatic patients. The more id is removed.1–10 Routine chest radiography
widespread use of procedural ultrasonography after thoracentesis is not supported in the
may explain some discrepancies between the literature in the absence of these risk fac-
early5,6 and more recent studies.1,8–10 tors.
Several studies have demonstrated that Some practitioners order chest imaging
postprocedural radiography is unnecessary un- after therapeutic thoracentesis to assess for
less a complication is suspected based on the residual pleural fluid and for visualization of
patient’s symptoms or the need to demonstrate other abnormalities previously hidden by
lung re-expansion.1,4,9,10 Clinical suspicion and pleural effusion, rather than simply to exclude
the patient’s symptoms are the major predictors postprocedural pneumothorax. Alternatively,
of procedure-related pneumothorax requiring postprocedural bedside pleural ultrasonogra-
treatment with a chest tube. Otherwise, inci- phy with recording of images can be done to
dentally discovered pneumothorax can usually assess for complications and residual pleural
be observed and managed supportively. fluid volume without exposing the patient to
radiation.11
■■ WHAT MECHANISMS UNDERLIE
Needle decompression and chest tube in-
POSTPROCEDURAL PNEUMOTHORAX?
sertion should be considered in patients with
Major causes of pneumothorax in patients tension pneumothorax, large pneumothorax
undergoing thoracentesis are direct puncture (distance from the chest wall to the visceral
Complications during needle or catheter insertion, the intro- pleural line of at least 2 cm), mechanical
duction of air through the needle or catheter ventilation, progressing pneumothorax, and
of thoracentesis into the pleural cavity, and the inability of the
symptoms.
include pain ipsilateral lung to fully expand after drainage
and anxiety, of a large volume of fluid, known as pneumo- ■■ KEY POINTS
thorax ex vacuo.5
pneumothorax, Pneumothorax ex vacuo may be seen in • Pneumothorax is a rare complication
patients with medical conditions such as en- of thoracentesis when performed by a
infection, skilled operator using ultrasonographic
dobronchial obstruction, pleural scarring from
subdia- long-standing pleural effusion, and lung malig- guidance.
phragmatic nancy, all of which can impair the lung’s ability • Mechanisms behind the occurrence of
pneumothorax are direct lung puncture,
organ puncture, to expand after removal of a large volume of introduction of air into the pleural cavity,
pleural fluid. It is believed that transient pa-
and death renchymal pleural fistulae form if the lung can- and pneumothorax ex vacuo.
not expand, causing air leakage into the pleu- • In asymptomatic patients, pneumothorax
ral cavity.5,8,9 Pleural manometry to monitor after thoracentesis rarely requires inter-
changes in pleural pressure and elastance can vention beyond supportive care and close
decrease the rates of pneumothorax ex vacuo observation.
in patients with the above risk factors.5 • Factors such as multiple thoracentesis at-
tempts, symptoms, clinical suspicion, air
■■ WHEN IS RADIOGRAPHY INDICATED aspiration during thoracentesis, presence
AFTER THORACENTESIS? of previous lung disease, and removal of a
Current literature suggests that imaging large volume of fluid may require postpro-
to evaluate for postprocedural complica- cedural lung imaging (eg, bedside ultraso-
tions should be done if there is suspicion nography, radiography). ■

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 MIRRAKHIMOV AND COLLEAGUES
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ADDRESS: Aibek E. Mirrakhimov, MD, Division of Pulmonary, Critical
Care, and Sleep Medicine, University of New Mexico, 915 Vassar NE, Suite
120, Mail Stop Code: MSC 11 6093, Albuquerque, NM 87131;
amirrakhimov1@gmail.com
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